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Across the state, more hospitals are mandating employees get a flu shot at the beginning of the “flu season,” but is it the best way to prevent the spread of flu in health care facilities?

By Stephanie Soucheray

The clips show up on the news every few days: Patients with sleeves rolled up, dutifully getting an influenza vaccination as the reporter explains that 2013’s flu season is one of the deadliest. The message is clear: Get your flu shot.

But it’s not just the local news that extolls the value of flu shots. For the last decade, state and national public health officials have urged anyone older than six months to get the flu shot each fall. Now local hospitals are making sure that their staff are among the inoculated each season, even as some question the mandate.

This coming September, WakeMed in Raleigh will require all employees to receive the vaccine as a condition of employment, following the trend set by other hospitals in the state such as Wake Forest Baptist Medical Center in Winston-Salem. If an employee provides a religious or medical exemption from getting the vaccine, they must wear a mask or face-covering during flu season.

Like other hospitals, WakeMed said their decision is based on science.

“Research has always shown that immunizing the people who take care of patients significantly reduces the instance of influenza in the hospital,” said Chris Ingram, medical director of WakeMed Infection Prevention and Occupational Health. “By immunizing our health care workers, we are not only protecting them but we are taking the necessary steps to protect our patients from influenza.”

But some physicians argue that the data on the flu vaccine isn’t strong enough to support mandates for health care professionals. This year, UNC Hospitals required all of its health care employees (including physicians) to receive the shot or lose admitting privileges.

Nortin Hadler, a UNC rheumatologist and the author of several books that criticize the health care system for the over-medicalization of America, initially refused to get the flu shot. Hadler does not believe the shot is efficacious enough to warrant a mandate.

“This is about a mandate that’s based on thin ice,” said Hadler, who finally did get the shot in January. “I was told in no uncertain terms and they would go after me, and I didn’t want to do that to my patients.”

Hadler said the science behind the shot, and the science often quoted by the Centers for Disease Control and Prevention (CDC), is not incontrovertible. The CDC reported in the Jan. 13 edition of the Morbidity and Mortality Weekly Report that this year’s vaccine was 60 percent efficacious for those who received the shot in the fall.

More recently , the CDC released a report stating that the vaccine was considerably less useful in patients over 65, with only a 9 percent rate of vaccine effectiveness. But the vaccine still has reduced influenza outpatient visits by one- to two-thirds, and for children between 6 months and 17 years of age the vaccine is approximately 60 percent effective.

Hadler disputes that 60 percent number, and points out that if the CDC reaches its goal each year in vaccinating 100 million people, many will suffer from adverse effects.

“There’s everything from Guillaume-Barre disease to a sore arm. I can tolerate risk if its proven,” said Hadler, who also noted that many of his fellow rheumatologists and immunologists resented UNC’s mandate. Besides, Hadler said, the threat of the flu is a complicated issue, not only because flu strains change each year – and sometimes multiple times within a season – but because the flu shot costs $150 per person.

“That’s a lot of money for something that’s surrounded by a lot of smoke,” said Hadler. He made it clear that he is not anti vaccinations; he said that as a doctor he has no problem celebrating successful inoculations like the polio vaccine, but that the flu shot is far from being as important as other shots.

For Cameron Wolfe, a clinical associate in the Duke University Division of Infectious Diseases, the issue is more clear cut.

During a sneeze, millions of tiny droplets of water and mucus are expelled at about 200 miles per hour. The droplets initially are about 10-100 micrometres in diameter, but they dry rapidly to droplet nuclei of 1-4 micrometres, containing virus particles or bacteria.Photo by James Gathanay, courtesy Centers for Disease Control and Prevention

“I wish some of my colleagues who dispute getting the vaccine could come to the ICU,” Wolfe said. He said that while it’s impossible to calculate hospital-acquired flu, he’s sure it exists in large part because staff are not vaccinated.

“For a healthy nurse or doctor, maybe the flu virus only produces some minor symptoms,” said Wolfe. “But when they introduce the virus to someone who is immune compromised, it can lead to death.”

According to the N.C. Department of Health and Human Services, there were 37 confirmed flu deaths in the state between Oct. 6, 2012 and Feb. 7. According to the CDC, anywhere between 5,000 and 50,000 Americans die from the flu each year, depending on the severity of the strain.

Both Hadler and Wolfe agree that the flu shot should not replace other barrier mandates in hospitals – frequent hand-washing, mouth-covering, limiting visitors and telling sick workers to stay home. But Wolfe said the CDC’s efficacy data is enough for him to recommend the vaccine for health care professionals.

“When someone says, ‘I don’t want to do this,’ I can’t say, ‘Here’s all this data,” said Wolfe. He pointed out that there are no comparative studies looking at hospitals that require employee flu shots and those that don’t; and because the flu strain changes each season, it’s hard for any sort of epidemiological study to matter one year to the next.

“I think the science is strong. But because of the nature of the flu, you’re not going to get proof,” said Wolfe, adding that he believes that even if the only hard data on giving health employees the flu vaccine is a reduction in sick days, that’s beneficial enough to a hospital.

“If 10 percent of your staff is out sick, and you have a 10 percent increase in patients during the busiest weeks of the flu, reducing staff illness is critical to keeping the hospital functioning,” Wolfe said.

So far, Duke has not taken the mandate approach to the flu vaccine, but Wolfe said the hospital’s goal is to have 100 percent compliance during the next flu season. That goal is in line with the CDC’s Healthy People 2020 goals, which aim for 90 percent of health care staff to be vaccinated against the flu each season.